The Efficacy and Safety of the Use of Non-Vitamin-K Antagonist Oral Anticoagulants in Patients with Non-Valvular Atrial Fibrillation and Concomitant Aspirin Therapy: A Meta-Analysis of Randomized Trials
Background—Current guidelines recommend non-vitamin-K antagonist oral anticoagulants (NOACs) as the first choice therapy in patients with non-valvular atrial fibrillation, as these drugs have several benefits over the vitamin-K antagonists (VKA). It is unknown whether these benefits remain when NOACs have to be combined with aspirin therapy. To assess the efficacy and safety of NOACs compared with VKA in patients with AF and concomitant aspirin therapy, we conducted a systematic review and study based meta-analysis of published randomized controlled trials (RCTs).
Methods—A systematic electronic literature search was done in MEDLINE, EMBASE and Cochrane CENTRAL Register of Controlled Trials for studies including published data (i) of patients age ≥18 y with non-valvular AF; (ii) randomizing to either VKA or NOACs; (iii) patients receiving aspirin therapy at any time during the study; and (iv) reporting on all-cause stroke or systemic embolism, vascular death, myocardial infarction, major bleeding and/or intracranial hemorrhage as an outcome. Hazard ratios (HR) with 95% confidence intervals (CIs) for each outcome were extracted from the individual studies and pooled using random-effects meta-analysis.
Results—This study based meta-analysis was restricted to the subgroups of patients on aspirin therapy (n=21,722) from four RCTs comparing VKA and NOACs (N=71,681) in non-valvular AF. In this meta-analysis including patients on mainly low-dose aspirin, NOACs were found to be more effective (outcome stroke or systemic embolism HR: 0.78 [95% CI, 0.67-0.91] and vascular death HR 0.85 [0.76-0.93]) and as safe as VKA with respect to major bleeding (HR: 0.83 [95% CI, 0.69-1.01]). NOACs were safer with respect to the reduction of intracranial hemorrhage (HR: 0.38 [0.26-0.56]).
Conclusions—This study based meta-analysis shows that it may be both safer and more effective to use NOACs as compared with VKA to treat patients with non-valvular AF and concomitant aspirin therapy.
- atrial fibrillation
- antiplatelet therapy
- coronary artery disease
- percutaneous coronary intervention
- Received March 22, 2017.
- Revision received October 16, 2017.
- Accepted October 19, 2017.